Professional Documents
Culture Documents
Use this form to report accidents, injuries, medical situations, or student behavior incidents. (Incidents involving a crime or
traffic incident should be reported directly to the Campus Public Safety office.) If possible, the report should be completed
within 24 hours of the event. Submit completed forms to the President’s Office.
Description of Incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible
(attached additional sheets if necessary)
I went into her room to introduce myself and ask if she wanted breakfast, but I noticed her struggling to get up. So, I went
towards her asking if she needs help and I tried to help her not fall, she then hit me with her cane.
REPORTER INFORMATION
Individual Submitting Report (print name)
Genevieve Cervantes
Signature
Genevieve Cervantes
Date Report Completed
June 20, 2018
Document any follow-up action taken after receipt of the incident report.
Talk to Ms. Lawry and tell her that the nurse she hit was her new nurse Supervisor
Apologize to the injured nurse for not warning her about the stuff in Supervisor
Ms. Lawrys’ file.
Be sure to read the patients file when you are assigned to be their new Injured nurse
nurse.
Tell Ms. Lawry to try to stay calmer when new people show up. Supervisor